carer’s needs assessment · web viewhave less time to spend with other members of your family,...

Carers Needs AssessmentSupported Self Assessment

A carer is someone who, without payment, provides help and support to a partner, child,relative, friend or neighbour, who could not manage without their help. This could be due to age,physical or mental illness, addiction or disability.

Anyone can become a carer; carers come from all walks of life, all cultures and can be of anyage.

Many carers do not consider themselves to be a carer; they are just looking after their mother,son, or best friend, just getting on with it and doing what anyone else would in the samesituation.

This form is for you to tell us what impact caring has on you and your life, and whether you arewilling and able to continue to provide this care. It also looks at whether you would like tochange anything about your caring role at the moment. For example, you may find that youhave less time to spend with other members of your family, or are finding it hard to have time foryourself.

This form is designed to be a supported assessment, which means you should complete thisform with support from someone, for example a social worker, family, friends or someone from avoluntary organisation.

You will see in the assessment areas for the person supporting you to add in comments; this isto make sure the assessment is a true reflection of your situation. Our experience is that carerstend to underestimate the amount of care they provide. Some questions have an extra‘assessor’s view’ tick box for your social worker or assessor to complete. They, together withtheir manager, also make the decision about whether you get a Personal Budget or not.You may hear people referring to a ‘SAQ’, which is what this form is.

We have divided the form into 8 sections. In each section, please tick the box that bestdescribes your situation. There is space at the end of each section for you to add in anythingelse that will help us to understand your situation and what you want to achieve better.Once you have completed the form, please return it to the Access & Advice Service, 222 Upper Street, N1 1XR or email it to [email protected]

if you have completed it with the help of a social worker or support worker, they will take it back with them.

Once social services have received your form, someone will be in touch to discuss supportoptions with you and information and advice that may be helpful in your caring role.If you already have a social worker or support worker then they will discuss what options maybe available with you and whether you are eligible for funding to support you in your caring role,such as money towards gym membership or help with housework etc.

Carers Needs Assessment – Self Assessment Questionnaire v2.0 (Nov 2009) of 9

mailto:[email protected]

1. Information about you and the people you care for

About youYour first name Your last name Your date of birth Your telephone number Your address Your postcode Your ethnicity Your gender

About the person who assisted you in completing this formFirst name Last name Relationship to you Telephone number Address Postcode

Are you registered with a Carer’s Hub? Please provide details

About the person you care forFirst name Last name Date of birth Home Phone Number Alternative Telephone Number (eg. mobile, work etc.) Address (if they do not live with you) Postcode Their relationship to you (e.g. son, mother, friend etc.) Have they been assessed by Social Services? Yes No Not sureTheir ethnicity Their GP (name & practice) Can you provide confirmation that you are caring for this person e.g. GP/OT/therapists letter

Carers Needs Assessment – Supported Self-Assessment 2015 of 9

2. What you do for the person you care forPlease tell us about the help that you give now (or think you may have to give in the near future) and whether you are willing and able to continue to give this. Please check all boxes that are relevant.

I don’t help the person I care for with this

I sometimes help with this

I do all of this for the person

I care for

I can’t/don’t want to

continue to do this

Washing/BathingDressing

Getting in or out of bed

Assisting to the toiletMeal preparationSupervision of eating and drinkingShopping

Laundry

CleaningMoney management for them, e.g. paying billsCorrespondence and paperworkDriving / arranging transportEscorting to keep in touch with family and friendsEscorting to use community facilities and services (e.g. the library)Making sure they are safe

Dealing with crises

Helping them to take medicinesSupporting them emotionallyOrganising appointments / visits. E.g. with GPs, hospital, social servicesManaging a direct payment / other support for them


Is there anything else you would like to tell us about what you do for the person you care for?

Please provide further details including anything you would like to change

Do you care for anyone else, including children?

3. My caring rolePlease tell us about the day-to-day and long term effect of caring

Carer’s View

NO IMPACTMy caring role does not interfere with my life or stop me from doing anything I want

MILD IMPACTMy caring role has a small effect on how I live my lifeMODERATEMy caring role sometimes makes it difficult to carry out my day-to-day activities, work or education and/or has some effect on my healthSEVEREMy caring role often makes it difficult to carry out my day-to-day activities, work, education or seeing friends and family and/or affects my healthVERY SEVEREMy caring role effects every part of my life and I have very little or no time to look after myself, my health or to work, study or see family and friends

Other support Please let us know if the people you care for get support from anyone else. For example, social services, family, friends, neighbours etc. Please let us know what they do for the person/s you care for.

Do you receive any other support from any other organisation, friends or family members in carrying out your caring role?


4. Time for you

Keeping yourself well

Physical health and wellbeingWhen considering the support you provide how does this affect your health and well-being? For example, are you able to get a full night’s sleep? Do you have back problems or get headaches that are made worse by caring?

Please choose the sentence that most closely applies to your situation. Please check one box only.

Carer’s View

a. My role as a carer does not affect my own physical health.

b. My role as a carer sometimes affects my own physical health.

c. My role as a carer often affects my own physical health.

d. My role as a carer means that I am not able to look after my own physical health.

Desired outcomes and further details

Mental Health and wellbeingWhen considering the support you provide how does this affect your mental health and well-being? For example, do you find caring very stressful? Do you often feel unable to cope or feel depressed?


Carer’s View

a. My role as a carer does not affect my mental wellbeing

b. My role as a carer sometimes affects my mental wellbeing

c. My role as a carer often affects my mental wellbeing

d. My role as a carer means that I am not able to look after my mental wellbeing



Having a break This is about having some time to yourself during the week away from the demands of your caring role. This could mean you are able to practise your religion, meet up with friends or family, spend quality time with your children and other family members, or have a social life.


Carer’s View

a. I am able to have time for myself and do the things that are important to me when I need to.

b. I have some time for myself, but I feel that more time off from my caring role would enable me to do the things that are important to me.

c. I have little time for myself. The opportunity to have some more time off would enable me to do the things that are important to me.

d. I have no time for the things that are important to me. Without some more time off I will have great difficulty continuing my caring role, because of my high levels of stress.


5. Work and learningYou may be working or studying at school, college or university at the moment or you may feel that going back to work or studying is not even a possibility.

Please let us know whether you are working or studying at the moment. Please choose the sentence that most closely applies to your situation. Please check one box only.

a. I work / study full time and combine work / studying and caring

b. I work / study part time and combine work / studying and caring

c. I am retired / I am not studying / I am unemployed

d. None of the above apply to me

Please let us know what your situation is. Please choose the sentence that most closely applies to your situation. Please check all the boxes that apply.

a. I have had to reduce my hours at work / study because of my caring role.

b. I am finding it hard to stay in work / keep up with my studies because of my caring role

c. I have had to stop working / studying because of my caring role


Desired outcomes and further details including anything you would like to change

6. Support for you in your caring role

Training for you in your caring roleYou may feel that you would like some support in how to carry out some aspects of your caring role. You may also like some more information on the condition of the person you care for. Please check all the boxes that apply.

a. Do you need any training to support you in your caring role? This could be stress management, first aid, moving and handling, managing continence, managing medication etc.

b. Would you like more information on the condition of the person you care for?

Desired outcomes and further details including any specific training courses you would like to go on

Emotional supportThis is about whether you feel able to talk about your caring role with someone you are comfortable with and to discuss it honestly. For example, if you are feeling under stress or finding life particularly difficult, are you able to talk about this openly, honestly and in confidence? Would you like more emotional support?


a. I am always able to discuss my feelings about my caring role.

b. I am sometimes able to discuss my feelings about my caring role.

c. I rarely have the opportunity to discuss my feelings about my caring role. I feel I would like more emotional support.

d. I have no opportunity to discuss my feelings about my caring role and I feel I need more emotional support.



Financial SupportWould you like some information or advice on benefits? Yes No


Is there anything else you would like to tell us about the support that you need in your caring role?

7. Thinking about the answers you have given, are you willing to continue being a carer?

Yes with support No

If you have ticked ‘No’, please let us know why and what you would like to happen next:

Thank you for completing this assessment. Please sign, date and return it to the Access and Advice Team, 222 Upper Street, N1 1XR or to your allocated worker. Once we receive the form, we will discuss your needs with you and send you a support plan based on what we agree.

In the meantime, if you have any questions about this assessment, please contact either your nominated worker or the Access and Advice Team on 020 7527 2299.

I confirm that the information provided on this form is a true statement of my situation and needs at this time

Carer’s Signature…………………………………………………………………….

Carer’s Name…………………………………………………………………………

Date…………………………


8. Declaration of consent to share information

Please read and tick box

Family Name: First Name:

NHS ID: Social Services ID: Date of Birth:

I understand that the information I give may need to be seen by other health and social services staff in providing my care and sharing information to facilitate beneficial communication.

I understand that information about me may be exchanged and stored on computer, and that this will only be used in accordance with the Data Protection Act 1998.

I agree to information about me being shared as specified below where this is necessary to assess my health and social care needs and facilitate agreed support, treatment or services.

Please tick one box only

I agree to all information being shared with all the people who need it

OR

I agree to information being shared only as specified below:

Information is not to be shared with the following people or organisations:

I am happy for you to contact the person/agent who has assisted in completing this form

The following type of information is not to be shared such as types of medical information/diagnosis or social/personal information:

Please note: On rare occasions it may be necessary to share information without asking you. This can happen when we are worried about your physical safety or we need to take action to protect you from serious harm. If this happens, we will make a record of what was shared and with whom and let you know as soon as it is safe to do so.

Carer’s signature Date


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